JHCPU 24.2 / May 2013

This issue is large and comes with a supplement. First, the supplement: The Health Resources and Services Administration (HRSA) and The National Institute on Minority Health and Health Disparities at the National Institutes of Health (NIMHD/NIH) jointly sponsored the supplement collection, titled Advancing Obesity Prevention: Quality Improvements, Emerging Models and Best Practices. The Guest Editors are Nishadi Rajapakse, PhD, MHS; Richard Berzon, DrPH, PA; Sarah Linde, MD; Natasha Coulouris, MPH; Ligia Artiles, MA; Eliza Heppner, MPA. The supplement shines a light on advances sponsored with federal funds in the national trek towards healthy weight.

The articles in the regular issue are arranged into five parts:

PART 1: HOMELESSNESS
PART 2: IMMIGRATION, BORDERS, LANGUAGE
PART 3: PRIMARY CARE AND CANCER
PART 4: INNOVATIVE PROGRAMS
PART 5: HEALTH POLICY AND EPIDEMIOLOGY

Before these five parts, readers will find our regular ACU Column, which this month concerns the important role that community health centers can play in family planning.

PART 1: HOMELESSNESS
The six papers that open this issue directly concern people who are homeless. The first emerges from work conducted by Health Care for the Homeless (in collaboration with Harris County [Houston] officials and the Baylor College of Medicine) to connect people released from jail immediately with behavioral health services as a means of preventing their relapse into homelessness (C. Brown et al.). The second focuses on release from hospitalization and the quality of the care that people who are homeless receive in those circumstances (Greyson et al.). The third paper reports on geriatric syndromes (including falls, cognitive impairment, frailty, major depression, sensory impairment, and urinary incontinence) in homeless adults, identifying as risk factors such characteristics as having less than a high school education, medical comorbidities (diabetes and arthritis), as well as alcohol and drug use problems (R. Brown et al.). The fourth paper is a postdictive validity study of a Vulnerability Index, an instrument used to assess medical vulnerability among people who are homeless (Cronley et al.). Molinari and colleagues report on perceptions of homelessness among veterans, Veterans Administration staff, and providers of housing interventions, concluding that older veterans who are homeless may be more motivated to change than their younger counterparts, due to receiving less social support and facing greater challenges in employment and health. Finally, the systematic review that closes out this section continues the theme begun earlier in the papers about people who are homeless being released from jail and hospitals still in need of care: Doran and colleagues review the literature on respite care—care for homeless patients who are too sick to be on the streets or in a traditional shelter, but not sick enough to warrant inpatient hospitalization

PART 2: IMMIGRATION, BORDERS, LANGUAGE
This part includes 10 research papers concerning populations in the U.S. or on one of its borders who originate from other countries and/or who speak languages other than English. The first asks how physicians who have second language skills decide when to call an interpreter (Andres et al.), and reports on in-depth interviews about this with 25 such physicians in different practice settings. In a related paper, Radwin and colleagues analyze data collected at an urban safety-net hospital oncology unit to examine the relationships among race, language, patient-centered nursing care, and patient outcomes. They find that patients who speak a language other than English perceive nurses’ responsiveness differently from English-speaking patients, and in turn have less trust in nurses. They write: “[M]ore liberal use of interpreter services may be warranted with patients who do not speak English at home. More routine use of interpreters may enhance patient perceptions that the nurse respects the patient, is attending to the patient carefully, and that the nurse is demonstrating due concern for the patient.”

In a cross-cultural study, Lim and colleagues investigate health behavior changes after breast cancer treatment, reporting their qualitative comparisons of Chinese American, Korean American, and Mexican American survivors. On the topic of colorectal cancer screening, Lee and Im investigate the influence of culture on practice among Korean American immigrants. Two papers in this part concern Hmong populations: Fang et al. address cervical cancer screening and Kue and Thorburn address hepatitis B screening and vaccination among Hmong people in the U.S. Renfrew et al. investigate barriers to care for diabetics from Cambodia.

Border communities come into focus in the papers by Jiménez and colleagues (on the close connection between poverty and obesity) and Talavera-Garza and colleagues (on manufacturing workers’ access to and use of health care). Finally, we learn through a qualitative study about perceived mental health needs and priorities of the population of underserved Latinos in Montgomery County, Maryland (Watson et al.).

PART 3: PRIMARY CARE AND CANCER
As is the case for every issue, the heart of this one is in primary care and chronic care for medically underserved populations. The topic is vast.

As these subjects recur so often among the medically underserved, it is no surprise that some of the papers here concern colorectal cancer (Whitaker et al.), breast cancer (Allicock et et al.), vaccination for HPV (Aragones et al. and Perkins et al.), and asthma (Martin et al.). Others take us into new territory: Mieh and colleagues write about home-based caregiving for people living with HIV/AIDS in South Africa, and Bipasha Biswas writes about the health of women and children in the Sundarbans Islands.1

How best to connect primary care with specialty care is a question with a lot of currency right now, as health care reform through the Affordable Care Act comes into being. Two papers here bear on that question: Handy and colleagues identify barriers to specialty care for uninsured patients in East Baltimore, and in a Commentary Mark Hall advocates one way of overcoming just this kind of barrier.

The legal system influences health and can provide opportunities for better care, whether they are exploited or not. Pettignano and colleagues report on seven years’ worth of data from the Health Law Partnership, a collaborative endeavor between Children’s Healthcare of Atlanta, the Atlanta Legal Aid Society, and Georgia State University College of Law. Of 250 cases accepted by the legal team after administering what they refer to as a legal check-up to patients in need, most concerned housing (19.6%), family law (18.0%), disability/SSI (17.2%), education (16.4%), and Medicaid (10.0%). Children in foster care are by definition involved in the legal system: Landers and colleagues compare their preventive visits with those of other children on Medicaid.

At the other pole of the legal system from ensuring the health of children is prison and the health of people who endure it. Harner and Riley report on their qualitative research with incarcerated women on how prison has affected their health.

Finally, this part of the present issue includes a fascinating paper on medical skepticism and the use of complementary and alternative medicine by older, rural African Americans and Whites (Bell et al.). The authors report a high degree of skepticism but little connection to either race/ethnicity or use of complementary therapies.

PART 4: INNOVATIVE PROGRAMS
Innovations in care for underserved populations may motivate both providers and communities in their efforts to improve health. Etienne Phipps and colleagues from Philadelphia report on their program to provide financial incentives for low-income families to buy more fruits and vegetables. Participants received pre-paid coupons to buy fresh produce at the study store during the intervention period. A financial incentive provided by study coupons increased the average weekly purchase of fresh fruit but was less successful with fresh vegetables.

Hepatitis C virus (HCV) infection is a chronic condition requiring specialized provider knowledge. As access to specialists for low-income patients is often impeded, when they have HCV such patients may face severe long-term health problems such as liver failure. Project Extension for Community Healthcare Outcomes (Project ECHOTM)—originally developed at the University of new Mexico—is an innovative program that uses teleconferencing, case-based learning, and disease management to expand access to specialty care for underserved patients. In weekly Project ECHO teleconferences, a faculty team of specialists make presentations, followed by primary care providers presenting individual cases. The Community health Center, Inc., Connecticut’s system of federally qualified health centers, (FQHCs) studied and tailored Porject ECHO to their needs for treating HCV in FQHCs. Kushbu Khatri and colleagues write very informatively about that endeavor here.

Low levels of compliance with U.S. Public Health Service recommendations for supplemental folic acid consumption by pregnant women—especially among Latinas—motivated Lamb and colleagues from the University of Oklahoma College of Pharmacy to hold a multi-faceted promotional event at a YWCA in Oklahoma City, work on which they report here. Angier and colleagues, in an effort to increase the relevance of research to underserved communities, went on a retreat with community health workers so researchers and front-line staff could engage with one another about what health concerns they find most pressing.

PART 5: HEALTH POLICY AND EPIDEMIOLOGY
Health policy and epidemiology generate interleaving results. This section begins with the implementation of a data-collection process advocated by the Institute of Medicine (IOM). Detailed ethnicity data—granular ethnicity—can help identify and target health disparities more precisely, in the IOM’s view. Here, Wilson and colleagues from the Institute for Family Health in New York (a group of 17 community health centers) report on that organization’s ground-breaking efforts to collect granular ethnicity data, and on the application of that information to improving diagnosis of hepatitis B.

Next, two Commentaries address new legislative efforts to improve health. Ramirez and Safford look from two sides at California’s Senate Bill 1413 of 2010, which requires school districts to offer free fresh water at mealtimes. On first glance, the bill seems to promise institutional commitment to fighting childhood obesity. However, it has had the unintended consequences of squeezing the already tight budgets of schools in very low-income areas, especially those with contaminated tap water. The question of how simultaneously to achieve viable public health improvement programs in schools without hampering their central mission of education comes to the forefront. Rodriguez and colleagues address another important issue arising in many states in their Commentary on the merits of licensing mid-level dental providers in the absence of an adequate number of dentists.

This issue concludes with four research papers. Lee and Hicken analyze social risk and racial/ethnic disparities in obesity during the transition to adulthood. Onoye and colleagues in Hawai’i at Mānoa examine emergency room use by patients with mental health disorders (especially PTSD). Harking back to the Commentary on mid-level dental providers, Wallace and MacEntee from the University of British Columbia report on their interviews with dentists (n=4), dental hygienists (n=30), dental clinic staff (n=17), and other health care and social service providers (n=12) about increasing numbers of community dental clinics in low-income areas. They conclude that “unmet dental need of vulnerable people requires political attention and that restricted dentistry for underserved communities is socially unacceptable.” Finally Wright and Ricketts investigate whether the proportion of consumers on FQHC governing boards is associated with their use of federal grant funds to provide uncompensated care, concluding that it is not.

Before closing, I would like to alert readers to a new book. Johns Hopkins University Press (JHUP) has just published our collection of papers on free clinics and student-run clinics, with a preface by Dr. Charles Mouton (Dean of the School of Medicine at Meharry). This collection of over 30 papers seeks to represent the great variety of responses to the needs of people who are uninsured throughout the United States. The title is Free Clinics: Local Responses to Health Care Needs. It is available on Amazon and through JHUP.

Virginia M. Brennan, PhD, MA
Associate Professor, Meharry Medical College
Editor, JHCPU

[1] The Sundarbans Islands lie outside our geographic scope (in West Bengal, India), but we include this paper because of the importance of infant mortality as a theme in JHCPU. We do not anticipate any more such exceptions to our scope (North and Central America, the Caribbean, and sub-Saharan Africa) in the future.

From the Journal of Health Care for the Poor and Underserved

February 2013

Chau-Kuang Chen, EdD
Michelle Bruce, MD, MSPH
Lauren Tyler, BS
Claudine Brown, MSPH
Angelica Garrett, MD
Susan Goggins, MD
Brandy Lewis-Polite, MD
Mirabel L Weriwoh, MD, MSPH
Paul D. Juarez, PhD
Darryl B. Hood, PhD
Tyler Skelton, MS

The authors are affiliated with the Department of Institutional Research at Meharry Medical College (MMC) [C-KC]; Department of Internal Medicine, MMC [MB]; the Department of Biology, Tennessee State University [LT]; the School of Medicine at MMC [AG, SG, B L-P]; the School of Graduate Studies and Research, MMC [CB, MLW]; the Department of Family and Community Medicine, MMC [PDJ, TS]; and the Department of Neuroscience and Pharmacology, NIMHD Health Disparities Research Center of Excellence, Environmental Health Disparities and Medicine, Center for Molecular and Behavioral Neuroscience, MMC [DBH]. Please address correspondence to Darryl B. Hood, PhD, Professor, Department of Neuroscience and Pharmacology, NIMHD Center of Excellence in Health Disparities, Center for Molecular and Behavioral Neuroscience, Meharry Medical College, Nashville, TN 37208; (615) 327-6358; dhood@mmc.edu.

Abstract: The goal of this study was to analyze a 54-item instrument for assessment of perception of exposure to environmental contaminants within the context of the built environment, or exposome. This exposome was defined in five domains to include 1) home and hobby, 2) school, 3) community, 4) occupation, and 5) exposure history. Interviews were conducted with child-bearing-age minority women at Metro Nashville General Hospital at Meharry Medical College. Data were analyzed utilizing DTReg software for Support Vector Machine (SVM) modeling followed by an SPSS package for a logistic regression model. The target (outcome) variable of interest was respondent’s residence by ZIP code. The results demonstrate that the rank order of important variables with respect to SVM modeling versus traditional logistic regression models is almost identical. This is the first study documenting that SVM analysis has discriminate power for determination of higher-ordered spatial relationships on an environmental exposure history questionnaire.

The socioeconomic circumstances of people and the places where they live work and play strongly influence their health.1 Healthy homes are essential to a healthy community and serve to protect families from exposure to potential environmental contaminants (such as chemicals and allergens) thereby preventing exposure-related phenomena. In contrast, inadequate housing contributes to infectious and chronic disease and injuries and has been shown to affect child development adversely.1 The definition of inadequate housing is related to the basic structure and systems of a housing unit, whereas the definition of unhealthy housing is related to exposure to environmental pollutants and other toxicants.1 The Centers for Disease Control and Prevention (CDC) has defined unhealthy housing as housing with characteristics that might negatively affect the health of its occupants, including rodents, water leaks, peeling paint in homes built before 1978, and absence of a working smoke detector.

The most recent CDC report concludes that efforts to decrease disparities in access to healthy housing will have the immediate effect of decreasing disparities in health status.1 Among the approximately 110 million housing units in the United States, approximately 5.8 million are classified as inadequate, and 23.4 million are considered unhealthy. Inadequate and unhealthy housing disproportionately affect populations that have the fewest resources (e.g., people with low incomes and limited education). Studies reveal that certain ethnic and racial populations (such as African Americans), have a greater likelihood of residing in areas in which there is poor housing and poor air quality primarily defined in terms of fine particles (PM2.5).2 Minority populations are especially vulnerable and susceptible to exposure to PM2.5 as a result of their homes being located in close proximity to the emissions from smokestacks and vehicles (heavy traffic volumes).3,4 Historical studies have shown that vulnerable segments of minority populations, such as pregnant women and young children, are particularly susceptible to the effects of PM2.5 air pollution.5–8 These facts illustrate the need to develop survey instruments for the physician to have at his fingertips when taking initial environmental exposure histories. This is particularly relevant for physicians practicing in indigent care hospitals where many health problems plague urban minority populations with low socioeconomic status.

Recent reports on exposure during pregnancy to components of air pollution have revealed deleterious effects on development of the fetus. High levels of components of photochemical smog, including carbon monoxide (CO), nitrogen dioxide (NO2), and ambient particulate matter (PM2.5) have been associated with very low and low birth weight, preterm birth, and infant mortality.9,10 Particulate matter is material that is suspended in the air in the form of minute solid particles or liquid droplets as an atmospheric pollutant. Such environmental contaminants have also been associated with significant differences in biparietal diameter and head circumference both measured during pregnancy and at birth.11,12 In utero exposure to polycyclic aromatic hydrocarbons (PAHs) during pregnancy has been shown to correlate with impaired cortical function and cognitive developmental delay.13–17

A recent epidemiologic study reported that use of gas appliances and increased NO2 in the home during the first three months of life are associated with decreased cognitive test scores and increased inattention at four years of age.18 In a separate study, Suglia and colleagues estimated lifetime residential exposure to carbon black, a proxy for traffic-related PM, among 8–11 year old children with an associated decline in performance on intelligence and memory tasks as a function of increasing carbon black levels.19 Interestingly, autism spectrum disorder has been associated with estimated regional concentrations of hazardous air pollutants, including arsenic and nickel, and with diesel PM exposure in early childhood.20 Thus, there is an emerging literature suggesting that nearby roadway traffic-related air pollutants, possibly influenced by specific components such as particulate matter or PAHs, adversely affect neurodevelopmental processes.

In the present study conducted out of Metro Nashville General Hospital at Meharry Medical College, we have used support vector machines (SVM) to analyze responses to a 54-item environmental exposure questionnaire towards validation of the instrument for future use in recruiting pregnant women for prospective longitudinal studies. Support vector machines are a relatively new classification or prediction method developed by Cortes and Vapnik21 in the 1990s as a result of the collaboration between the statistical and the machine-learning research communities. Support vector machines attempt to classify datasets by finding a separating boundary, referred to as a hyperplane. The main advantage of the SVM is that it can, with relative ease, overcome the high dimensionality problem, i.e., the problem that arises when there is a large number of input variables relative to the number of available observations.22 Further, because the SVM approach is data-driven and possible without a theoretical framework, it is believed to have important discriminative power for classification, especially with datasets where sample sizes are small.23 The technique has recently been used to improve methodology for detecting diseases in clinical settings.24,25 The SVM analysis of responses from this study will serve as a point of reference for recruitment of a prospective cohort of pregnant African American women living in an inner city environment to quantify the frequency of exposure related adverse pregnancy outcomes. (841 words)

Methods

Demonstration of similarity of demographics between inner-city Atlanta area (Grady Memorial Hospital) and inner-city Nashville area (Metro Nashville General Hospital at Meharry Medical College) as a means to validate our 54-item instrument. All procedures in accordance with administration of the 54-item instrument within the subspecialty clinics at Nashville General Hospital at Meharry Medical College were submitted to the Meharry Medical College Institutional Review Board (IRB). The Institutional Review Board determined that the project was exempt, based on category 45 CFR 46.101.b (2) of the federal regulations concerning the use of survey procedures when the information is recorded in such a manner that subjects cannot be identified. No consent form was needed and the IRB application was approved (IRB number 051115DBH195-11).

Our 54-item environmental exposure instrument is an adaptation of the Agency for Toxic Substances and Disease Registry (ATSDR) environmental exposure history questionnaire (http://www.atsdr.cdc.gov/hec/csem/exphistory/docs/exposure_history.pdf.) and therefore required validation and calibration. As a means of validating our instrument, we sought to determine the similarity of demographic characteristics between inner-city Atlanta, Georgia and inner-city Nashville, Tennessee based on 2000 and 2010 census data. For additional clarity, we also determined the similarity of demographic characteristics between the Grady Memorial Hospital area and the Metro Nashville General Hospital at Meharry area. These data are shown in Table 1 and indicate that the respondent population at Grady Memorial Hospital in inner-city Atlanta and the respondent population at Metro Nashville General Hospital at Meharry are very similar in terms of the Black and/or African American representation. The percent differences in 2012 demographic data for Atlanta compared with Nashville in favor of Atlanta (16.4%) is offset by the robust African American demographic (97.3%) in ZIP code 37208 (where Metro Nashville General Hospital at Meharry is located). The Grady Memorial Hospital area’s African American population represents 76.3%of the total population in the area. There are similar percent differences between the Atlanta Grady Memorial Hospital area and the Metro Nashville General Hospital at Meharry area in educational attainment, sex, and school enrollment. All of these indices proved important as a part of the calibration-validation process regarding our 54-item instrument.

Study subjects. A total of 187 child-bearing-age (18–35) African American or Hispanic women were interviewed when presenting for services at the Obstetrics and Gynecology, Family and Community Medicine, or Pediatrics subspecialty clinics at Metropolitan Nashville General Hospital at Meharry Medical College.

Personal interview. The 54-item environmental exposure questionnaire was administered to consenting eligible child-bearing-age (18–35 years) African American and Hispanic women. The survey was partitioned into five domains including 1) home and hobby, 2) school, 3) community, 4) occupation, and 5) exposure history. Demographic information pertaining to the woman’s age and education level were recorded, as was the ZIP code in which she primarily resided. This 54-item questionnaire was modeled from both the CDC and the ATSDR environmental exposure history questionnaires.26

Exposed vs. control dichotomization of ZIP codes. Based on the proximity of EPA reporting sites with emissions to Meharry Medical College-respondents that resided in ZIP codes 37206, 37207, 37208 and 37209 were assigned to the exposed group. Respondents residing in any other ZIP codes (37210, 36606, 37011, 37013, 37062, 37075, 37076, 37082, 37086, 37087, 37115, 37219, 37138, 37203, 37210, 37211, 37212, 37213, 37214, 37215, 37216, 37217, 37218, 37219, 37220, 37221, 37228, 37235, and
38556) were assigned to the control group.

Overview of the SVM classifier. The SVM algorithm is a supervised machine learning method which has demonstrated its ability to solve complex classification problems, especially in the field of bio informatics.27,28 The SVM model is operated on the principle of structural risk minimization.29 It is designed to minimize true risk of misclassifying examples during the model training. It has its advantage in the practical application for
small sample and generalization because of structural risk minimization.29–31

Unlike many other more popular data analysis tools, the SVM algorithm is data-driven and model-free and, as such, may have much discriminative power for classification in instances where many explanatory variables are used and the sample size is relatively small. Support vector machines establishes sophisticated models by constructing a multidimensional hyperplane optimally discriminating (maximizing the margin separation) between two different classes.32 The algorithm achieves its high discriminative power by using special non-linear functions called kernel functions to transform the original data into a high-dimensional space.33 Justified by Cover’s theorem, any dataset can be separated out if the data dimension grows.

Data analysis. A database was created from the collected responses. Entries with missing data points were excluded from the analysis and key domains of interest were identified. The overall response rate to the 54-item instrument was (94.3%). Our method converted the variable which spoke to the respondent’s neighborhood from a categorical variable (Rural, Suburban and Urban) into a dichotomous variable by combining the urban and suburban fields for the sake of parity. Respondents’ ZIP codes were dichotomized to form an exposure and control group with persons residing in the 37206, 37207, 37208 and 37209 ZIP codes being assigned to the exposed group based on the number of EPA reporting industrial facilities and sites coupled with their proximity to Meharry Medical College. Respondents residing in ZIP codes (37210, 36606, 37011, 03713, 37062, 37075, 37076, 37082, 37086, 37087, 37115, 37219, 37138, 37203, 37210, 37211, 37212, 37213, 37214, 37215, 37216, 37217, 37218, 37219, 37220, 37221, 37228, 37235, and 38556) outside of this area, were assigned to the control group. Data analysis was performed on the dataset using DTReg software for Support Vector Machine (Sherrod, PH., 2008, Digital Tree Regression (DTREG) (Version 4.0) [Software]. Brentwood, Tennessee) and SPSS version 17 for the logistic regression model (Statistical Product and Service Solutions (SPSS) (Version 17) [Software] Armonk, New York).

Six steps were systematically adopted to yield the most suitable SVM and logistic regression models to accurately classify respondents living in distinct ZIP code groups.

Step 1 involved generating a research dataset consisting of one dependent variable and multiple independent variables collected from respondent’s questionnaires.

In Step 2, the underlying models were developed by the difficult selection of kernel functions for the SVM. Thus, our only strategy was performed a trial and error process by applying all kernel functions. For SVM classifier, the following four kernel functions were readily available for model construction: linear, radial basis function (RBF), polynomial, and sigmoid.

In Steps 3 and 4, all possible SVM candidate models were trained and tested to achieve minimal classification error by means of adjusting parameters and performing cross-validation. For the SVM classifier, a five-fold cross-validation was implemented to minimize the bias generated by random sampling of the training and testing datasets. The input dataset was divided into five mutually exclusive subsets. One subset was used for testing and the remaining four were used to train the data. The process was repeated five times to ensure that the model was tested in each subset.

In Step 5, the most suitable SVM model was generated and compared with a logistic regression model to determine validity relative to our 54-item instrument. Initial data analysis was carried out by comparing the normalized importance, rank order of independent variables, and classification accuracy on the SVM to those of the logistic regression. The classification accuracy was compared by the measures of 1) sensitivity and 2) specificity, and 3) combined accuracy for each SVM classifier.

Sensitivity was defined as a measure of ability of the model to detect important variables associated with those respondents living in ZIP code’s 37208, 37209 and 37210. Specificity is a measure of the ability of the model to specify and delineate differences by the respondents living in ZIP codes that make up the control group.

In Step 6, the most important variables and related rank orders of variables for the SVM model were generated to facilitate variable selection and explanation. The normalized importance was calculated by dividing the value of the highest relative importance into the value of the other relative importance. The normalized importance provides a hierarchal viewpoint of the ranking of the explanatory variables.

Creation of relational database and Web portal for geographical information systems mapping. We have established a relational database and Web portal , in part, from the EPA databases listed at www.IMNashville.com. This Web portal enables us to 1) build the capacity to process and analyze large secondary databases; 2) conduct inter-disciplinary training; 3) use public participatory GIS; and 4) develop interactive mapping of health disparities and community assets and risk factors associated with environmental exposures. Emissions data from the EPA-databases listed below was converted into a mapping format to visually communicate the location of EPA reporting industrial plants with emissions in ZIP codes as a function of the ZIP codes of respondents to our 54-item instrument that perceived themselves vulnerable to exposure to contaminants.

USEPA databases used in the present study. The EPA reporting sites are defined as any site in Metro Nashville Davidson County that emissions data was available from the following EPA-databases 1) Air Quality Subsystem (AQS), 2) AIRS Facility Subsystem (AFS), 3) AIRS Data and 4) Toxic Release Inventory.

Air Quality Subsystem (AQS). The Air Quality System (AQS) is EPA’s repository of ambient air quality data. AQS stores data from over 10,000 monitors, 5,000 of which are currently active. Specifically, this EPA database contains measurements of ambient concentrations of air pollutants and meteorological data from thousands of monitoring stations operated by EPA, state, and local agencies.

AIRS Facility Subsystem (AFS). The Air Facility System (AFS) contains compliance and enforcement data and permit data for stationary sources of air pollution regulated by EPA, state and local air pollution agencies. The environmental regulatory community uses this information to track the compliance status of point sources with various programs regulated under the Clean Air Act. See the Clean Air Act enforcement page for information on enforcement activities.

Types of data found in in AIRS facility subsystem. A plant is a facility represented by its physical location and defined by property boundaries. Plant-level data include plant name, address, Standard Industrial Classification (SIC), U.S. Census Bureau North American Industry Classification System, and compliance status.

A stack is where emissions are introduced into the atmosphere. Stack-level data include the height and diameter of the stack as well as the temperature, flow rate, and velocity of the gas released into the atmosphere. Stack-level data is used in emission inventory reporting.

A point is a physical piece of equipment or a process that produces emissions. Point-level data include normal operating schedule and the percentage of annual activity occurring each season.

A segment is a component of a point process, such as fuel combustion, that is used in the computation of emissions. Segment-level data in AFS include Source Classification Code (SCC), annual process rate, and fuel parameters. Segment-level data is used in emission inventory reporting. Emission inventory data can be found at the Technology Transfer Network Clearinghouse.

AIRS data provide easy access to summaries of air monitoring data for the current and five prior years, the latest available estimates of air pollutant emissions from major point sources, the overall regulatory compliance status of those sources, and names of contacts in EPA and state/local air pollution agencies. All these data pertain to the criteria pollutants (carbon monoxide, nitrogen dioxide, sulfur dioxide, ozone, particulate matter, lead).

Toxics Release Inventory Program (TRI). The TRI database contains data on disposal or other releases of over 650 toxic chemicals from thousands of U.S. facilities and information about how facilities manage those chemicals through recycling, energy recovery, and treatment. One of TRI’s primary purposes is to inform communities about toxic chemical releases to the environment.

Results

Similarity of demographic characteristics between inner-city Atlanta area (Grady
Memorial Hospital) and inner-city Nashville area (Metro Nashville General Hospital at Meharry Medical College). A version of our 54-item instrument was administered previously to inner-city populations at Grady Memorial Hospital in Atlanta, Georgia. As a means of validating the instrument that was developed by our group, we sought to determine the similarity of demographics between inner-city Atlanta and inner-city
Nashville based on 2000 and 2010 census data. For additional clarity, we also determined the similarity of demographics between the Grady Memorial Hospital area and the Metro Nashville General Hospital at Meharry area, as discussed in the Methods section and as demonstrated on Table 1. All of the endpoints and indices contributed to the validation -process of our 54-item instrument.

SVM analysis. Shown in Table 2 are the dependent or outcome variable as residential ZIP code areas that were regrouped into a binary measure of one or two. The respondent population was split between ZIP codes for the respondents living in (37206, 37207, 37208, 37209) and other ZIP codes for respondents living in (37210, 36606, 37011, 03713, 37062, 37075, 37076, 37082, 37086, 37087, 37115, 37219, 37138, 37203,
37210, 37211, 37212, 37213, 37214, 37215, 37216, 37217, 37218, 37219, 37220, 37221, 37228, 37235, and 38556). The five domains of independent variables (community, home and hobby, school, occupation, and environmental exposure history) included Q6 (polluted lake/stream: Community); Q17A (in your home: Home and Hobby); Q17C (on your lawn or garden: Home and Hobby); Q22 (school neighborhood [urban or rural]); Q24A (carpeted classrooms: School); Q24E (windows that open: School); Q24F (moldy smell: School); Q25G (flood, water leaks: School); and Q26G (odorous cleaning products: School).

Approximately one-tenth (9%) of the survey respondents lived near a polluted lake/stream community (Q6). In terms of using pesticides, more than half (54%) of the survey respondents used them in their home (Q17A) while more than one-tenth (14%) used them on their lawn or garden (Q17C). More than half (53%) of the survey respondents indicated that their children‘s school was located in a rural area (Q22). While inspecting their children’s schools, the survey respondents revealed that more than half of the schools had carpet (51%) (Q24A), windows that opened (55%) (Q24E), and a moldy smell (61%) (Q24F). Furthermore, nearly one-tenth (8%) of the survey respondents reported flood and/or water leaks in their children’s school (Q25G), and more than three quarters (76%) of the survey respondents indicated that the schools used odorous cleaning products (Q26G).

Table 3 presents major findings using SVM and logistic regression modeling approaches with the latter approach being the traditional model used to measure a binary outcome. The backward procedure is one of the procedures used to select significant risk factors to form the logistic regression model. The model fitting the statistic, pseudo R-squared value was used to measure the success of this model by explaining the variations in the data. The Nagelkerke R squared value (0.32) was significantly different from zero, indicating that 32% of the variations in the binary outcome variable (residential ZIP codes) was accounted for by the risk factors. Using the SVM, the independent variables were assigned a normalized importance and given a rank order based on this normalized value. According to the sigmoid function of SVM, the variables by level of importance to the outcome were the following; Q17A (in your home), Q17C (on your lawn or garden), Q25G (flood, water leaks), Q6 (polluted lake/stream), Q24F (moldy smell), Q26G (odorous cleaning products), Q25E (child’s school—new flooring or furniture), Q22 (school neighborhood [urban or rural]), and Q24A (carpeting in classrooms). The Wald test of Logistic regression was used at different levels of p values, 0.001, 0.01 or 0.05, to determine the significant independent variables associated with the binary outcome (residential ZIP codes). The regression coefficients for the following explanatory variables, Q17A, Q17C, Q25G, Q6, Q24F, Q26G, Q24A were found to be significantly different from zero at given p values level mentioned above and using the Wald test.

Table 4 represents a summary of the measures of accuracy used to evaluate both of the data analysis techniques used. Sixty-one percent (61%) of respondents perceived little to no exposure within the 5-domains. Sixty-nine percent (69%) of respondents perceived that they were susceptible to environmental exposures within the five domains. The SVM method outranked the logistic regression analysis with respect to sensitivity, but not specificity. In terms of combined accuracy, both SVM and logistic regression models were comparable (69% vs. 70%), which in some instances may be considered low; however, an important measure of accuracy is the sensitivity criterion, the so-called power of the test. Model sensitivity determines if the tool used in the study was accurate in measuring the outcome variable. If more survey respondents who were exposed to the risk factors did not have the disease, then the overall study power would be weakened. The SVM was found to be a more sensitive model (69%) than the logistic regression model (63%), meaning that SVM has a greater ability to identify important variables related to the binary outcome (residential ZIP codes). On the contrary, logistic regression was found to have a greater ability to specify differences between the populations of interest (women residing in the ZIP codes; 37206, 37207, 37208, 37209) and the control group used (women residing in other ZIP code areas).

Mapping of EPA-Reporting Industrial Sites Located in the North Nashville ZIP Code 37208. Figure 1 shows the EPA-Toxic Release Inventory (TRI) and smokestack emission sites located in the North Nashville ZIP code 37208. The TRI sites are shown in squares and smokestack emission sites in circles. Mapping of EPA-reporting industrial sites located in the North Nashville ZIP code 37208 allows for visualization of the SVM analysis finding of identifying the important variable related to the binary outcome as residential ZIP code from respondents of the 54-item instrument.

Discussion

In this study we validated our 54-item instrument with SVM analysis. The validation of this questionnaire was set in an inner city area of Nashville, Tennessee (North Nashville) which is composed largely of an African American population. North Nashville is known to suffer from increased adverse health outcomes compared with whites in the same area of Davidson County.35 The respondent population at Grady Memorial Hospital in inner-city Atlanta and the respondent population at Metro Nashville General Hospital at Meharry were shown to be very similar in terms of various demographic characteristics including race, educational attainment, sex, and school enrollment. This 54-item instrument will be used in the very near future to recruit a large cohort of pregnant African American women into a longitudinal study designed to quantify perturbations in sensory function in their infants prior to 24 months. The primary study site, Metro Nashville General Hospital on the Campus of Meharry Medical College operates as the community’s public hospital to provide access to care for all the city’s residents—whether uninsured, underinsured or insured. As a result of the validation of our instrument, our hospital will continue to serve as the primary recruitment site for translational research projects under the Meharry-Vanderbilt Alliance umbrella. It will be an overarching hypothesis in the future that women living in ZIP codes 37208 and 37209 will have a higher perceived risk of exposure to environmental toxicants as compared to women living in the surrounding suburban areas.

Support vector machines have been widely used in various areas, such as recognition, reliability evaluation, bioinformatics and medicines, for survival time classification and assessment of the severity of many acute and chronic diseases.36 However, to our knowledge, this study is the first attempt to investigate perceived exposure to environmental contaminants by administration of a 54-item instrument in a population of child-bearing-age African American and Hispanic women via SVM. The novelty of our study was demonstrating the discriminative power of this SVM approach as compared with that of commonly used logistic regression models.

In association with other studies being conducted in our center, creation of environmental relational databases will serve as a means to promote civic engagement in vulnerable communities and neighborhoods in close proximity to Meharry Medical College. The database described here enables us to begin to analyze the relationships between physical, built, and social environments relative to the health status of persons living in targeted neighborhoods or communities. The long-term goal is to use the data to develop and implement targeted interventions to improve health conditions on a community level. Our Web portal (www.IMNashville.com) allowed us to bring together data on health outcomes with data on environmental conditions, assets (salutogenic features), and risk factors (pathogenic features). As indicated earlier, our approach builds on the ecological environmental justice framework that explores the role that salutogenic
(health-promoting) and pathogenic (health-restricting) built and social features play in driving health and health disparities in differentially burdened communities.37

For the purposes of such relational databases, the natural environment includes air, food, soil, water, and vegetation.38 Environmental hazards refer to the effects of the environment on a person’s health and the effects of human activity on the health of the environment. Such hazards can be toxicants in a physical space that can harm health. Natural environmental datasets in our relational database include: 1) Day and night land surface temperature (LST) data from NASA’s Moderate-Resolution Imaging Spectroradiometer (MODIS) satellite sensor (1-km spatial resolution); 2) Daily spatial surfaces of ambient fine particulate matter (PM2.5) generated by algorithms developed by scientists at the Universities Space Research Association (USRA) and NASA/Marshall Space Flight Center and using MODIS satellite data and EPA ground observations39 (10-km resolution); 3) Daily maximum/minimum air temperature and daily maximum heat index from the North American Land Data Assimilation System (NLDAS) forcing data (12-km resolution); and 4) Finer resolution (30-m and 60-m) datasets of Landsat-derived land cover/land use and LST for 1992 and 2006 for a focused study in Nashville/Davidson County.

The built environment has been found to play a major role in directing individual physical activity, and Nashville has made big strides in improving policies and regulations related to building and site design to improve the built environment for pedestrians and cyclists, including passage of (1) specific plan zoning; (2) revised subdivision regulations that have introduced a so-called walkable subdivision option for developers; and (3) a community-character manual that will guide future land-use planning.40 In the future, our relational database will allow for the analysis of relationships between changing characteristics of the built environment and occurrence of health disparities. Establishment of this relational database will allow us to build longitudinal datasets to track changes in environmental conditions and effects on health disparities both retrospectively and prospectively.

Our study however, is not without limitations. The primary limitation of this study is its relatively small sample size but this fact did not impact the ability to achieve statistical significance with regard to the determination of higher ordered relationships to responses on the 54-item instrument. The second limitation is that not all of the women who participated were pregnant at the time of interview. We are aware of the implications of this fact, and remain cautious as a result. However, given the demographic profile of the patient base at Metro Nashville General Hospital at Meharry Medical College, it is highly likely that the percent of unintended births will track with that observed in the United States (37%).41 Many studies on unintended childbearing including a comprehensive review by the Institute of Medicine42 and a recent white paper reviewing more than 60 additional studies on this topic,43 have also shown that births that were unintended by the mother are at elevated risk of adverse social, economic, and health outcomes for the mother and the child. Unintended births are associated with delayed prenatal care, smoking during pregnancy, not breastfeeding the baby, poorer health during childhood, and poorer outcomes for the mother and the mother-child relationship.44 Further, longer-term negative consequences for these children have been found by some longitudinal studies of unintended pregnancies that track the children into adulthood.45

Thirdly, our cross-sectional design does not allow any inference to be drawn with respect to the causal relationships among independent variables. Finally, our data is based on a 15-minute interview in an indigent care facility that is located in a known socioeconomically impoverished ZIP code. This fact may have contributed to the perception of exposure to pollutants as has been observed in Berkson’s bias.46 Connecting environmental problems with health disparities can be difficult due to limitations in the way health data are collected and made available.47 Many health databases and tables provide data only at the county level. Without a geo-coded reference at a sub-county level, these data are limited as to how they can be related to environmental hazards or exposures that typically are features of a small geographic area. In addition, the health data often tells us very little about how a person may have come in contact with an environmental hazard.

Conclusion. To our knowledge, this is the first study using SVM analysis determination of higher-ordered spatial relationships on an environmental exposure history questionnaire. Previous to this one, the study that most closely resembled this one used SVM to predict adherence to medication in heart failure patients. In that study, data about medication adherence was collected from patients at a university hospital through self-reported questionnaire. The data included 11 variables of 76 patients with heart failure. Mathematical simulations were conducted in order to develop a SVM model for the identification of variables that would best predict medication adherence. Using the sigmoid function via SVM analysis,47 the rank order of variables by level of importance to the outcome (of perceived exposure to environmental contaminants) were Q17A (in your home), Q17C (on your lawn or garden), Q25G (flood, water leaks), Q6 (polluted lake/stream), Q24F (moldy smell), Q26G (odorous cleaning products), Q25E (child’s school—new flooring or furniture), Q22 (school neighborhood—urban or rural), and Q24A (carpeting classrooms). The Wald test of logistic regression was used to determine the significance (at different levels of p values: .001, .01, or .05) of independent variables associated with the binary outcome (residential ZIP codes). The regression coefficients for Q17A, Q17C, Q25G, Q6, Q24F, Q26G, Q24A were found to be significantly different from zero at given p value level. Our Nagelkerke R squared value (0.32) was significantly different from zero, indicating that 32% of the variations in the binary outcome variable (residential ZIP codes) were accounted for by the risk factors indicated in the respective questions. In conclusion, SVM analysis was shown to have discriminate power for determination of higher-ordered spatial relationships on the 54-item instrument within the five domains studied in the target ZIP code.

Acknowledgments

This work was supported, in part, by NIH grants S11ES014156-06 and 1R56ES017448- 01A1 to DBH and 3P20MD000516-07S1 to PDJ and DBH. Also, critical to the conduct of these studies were grants from the Simons Foundation Autism Research Initiative, Research Centers in Minority Institutions (RCMI) G12RRO3032 and S06GM08037, Nuclear Regulatory Commission Grant NRC-27-10-515 as well as Meharry Medical College -Vanderbilt University Alliance for Research Training in Neuroscience Grant
(T32MH065782).

Notes

1. Raymond J, Wheeler W, Brown MJ, et al. Inadequate and unhealthy Housing, 2007 and 2009. MMWR. 2011 Jan; 60 Suppl: 21–27.
2. Berube A, Frey WH, Singer A, et al. Getting current: recent demographic trends in metropolitan America. Washington DC: Brookings Institution, 2009. Available at: http://www.brookings.edu/research/reports/2009/03/metro-demographic-trends.
3. U.S. Environmental Protection Agency. Integrated science assessment for particulate matter: final report. Washington, DC: U.S. Environmental Protection Agency, 2009. Available at: http://cfpub.epa.gov/ncea/cfm/recordisplay.cfm?deid=216546.
4. U.S. Environmental Protection Agency. Air quality criteria for ozone and related photochemical oxidants: final report. Washington, DC: U.S. Environmental Protection Agency, 2006. Available at: http://cfpub.epa.gov/ncea/cfm/recordisplay.cfm?deid=149923.
5. Cirera L, Rodriguez M, Gimenez J, et al. Effects of public health interventions on industrial emissions and ambient air in Cartagena, Spain. Environ Sci Pollut Res Int. 2009 Mar;16(2):152–61.
6. Johansson C, Burman L, Forsberg B. The effects of congestions tax on air quality and health. Atmospheric Environment. 2009 Oct;43(31): 4843–54.
7. Pope CA 3rd. Respiratory hospital admissions associated with PM10 pollution inUtah, Salt Lake, and Cache Valleys. Arch Environ Health. 1991 Mar–Apr;46(2): 90–7.
8. Wang S, Zhao M, Xing J, et al. Quantifying the air pollutants emission reduction during the 2008 Olympic games in Beijing. Environ Sci Technol. 2010 Apr;44(7): 2490–6.
9. Currie J, Neidell M, Schmieder JF. Air pollution and infant health: lessons from New Jersey. J Health Econ. 2009 May; 28(3):688–703.
10. Ritz B, Yu F. The effect of ambient carbon monoxide on low birth weight among children born in southern California between 1989 and 1993. Environ Health Perspect.1999 Jan;107(1):17–25.
11. Hansen CA, Barnett AG, Pritchard G. The effect of ambient air pollution during early pregnancy on fetal ultrasonic measurements during mid-pregnancy. Environ Health Perspect. 2008 Mar; 116(3):362–9.
12. Vassilev ZP, Robson MG, Klotz JB. Outdoor exposure to airborne polycyclic organic matter and adverse reproductive outcomes: a pilot study. Am J Ind Med. 2001 Sep; 40(3):255–62.
13. Bocskay KA, Tang D, Orjuela MA, et al. Chromosomal aberrations in cord blood are associated with prenatal exposure to carcinogenic polycyclic aromatic hydrocarbons. Cancer Epidemiol Biomarkers Prev. 2005 Feb; 14(2):506–11.
14. Perera FP, Rauh V, Whyatt RM, et al. Molecular evidence of an interaction between prenatal environmental exposures and birth outcomes in a multiethnic population. Environ Health Perspect. 2004 Apr; 112(5):626–30.
15. Perera FP, Tang D, Rauh V, et al. Relationship between polycyclic aromatic hydrocarbon-DNA adducts, environmental tobacco smoke, and child development in the World Trade Center cohort. Environ Health Perspect. 2007 Oct; 115(10):1497–502.
16. Perera FP, Rauh V, Whyatt RM, et al. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on neurodevelopment in the first 3 years of life among inner-city children. Environ Health Perspect. 2006 Aug; 114(8):1287–92.
17. Perera FP, Rauh V, Tsai WY, et al. Effects of transplacental exposure to environmental pollutants on birth outcomes in a multiethnic population. Environ Health Perspect. 2003 Feb; 111(2):201–5.
18. Morales E, Julvez J, Torrent M, et al. Association of early-life exposure to household gas appliances and indoor nitrogen dioxide with cognition and attention behavior in preschoolers. Am J Epidemiol. 2009 Jun; 169(11):1327–36.
19. Suglia SF, Gryparis A, Wright RO, et al. Association of black carbon with cognition among children in a prospective birth cohort study. Am J Epidemiol. 2008 Feb; 167(3):280–6.
20. Windham GC, Zhang L, Gunier R, et al. Autism spectrum disorders in relation to distribution of hazardous air pollutants in the San Francisco Bay Area. Environ Health Perspect. 2006 Sep; 114(9):1438–44.
21. Cortes C, Vapnik V. Support-vector networks. Boston, MA: Kluwer Academic Publishers/ Machine Learning, 1995; (20):273–97. Available at: http://image.diku.dk /imagecanon/material/cortes_vapnik95.pdf.
22. Verplancke T, Van Looy S, et al. Support vector machine versus logistic regression modeling for prediction of hospital mortality in critically ill patients with haematological malignancies. BMC Med Inform Decis Mak. 2008 Dec 5; 8:56.
23. Yu W, Liu T, Valdez R, et al. Application of support vector machine modeling for prediction of common diseases: the case of diabetes and prediabetes. BMC Med Inform Decis Mak. 2010 Mar 22;10:16.
24. Maglogiannis I, Loukis E, Zafiropoulos E, et al. Support vectors machine-based identification of heart valve diseases using heart sounds. Comput Methods Programs Biomed. 2009 Jul;95(1): 47–61.
25. Thurston RC, Matthews KA, Hernandez J, et al. Improving the performance of physiologic hot flash measures with support vector machines. Psychophysiology. 2009 Mar; 46(2): 285–92.
26. Agency for Toxic Substances and Disease Registry (ATSDR). Case studies in environmental medicine: taking an exposure history. Washington, DC: Agency for Toxic Substances and Disease Registry, 1992 Oct. Available at: http://www.atsdr.cdc.gov /hec/csem/exphistory/docs/exposure_history.pdf.
27. Rice SB, Nenadic G, Stapley BJ. Mining protein function from text using term-based support vector machines. BMC Bioinformatics. 2005; 6(Suppl 1):S22.
28. Ng KL, Mishra SK. De Novo SVM Classification of Precursor microRNAs from genomic pseudo hairpins using global and instrinsic folding measures. Bioinformatics. 2007 Jun 1;23(11):1321–30.
29. Vapnik V. The nature of statistical learning theory and application. New York, NY: John Wiley Publishing, 1995.
30. Wan V, Campbell WM. Support vector machines for speaker verification and identification. Presented at: IEEE International Workshop on Neural Networks for Signal Processing. Sydney, Australia, 2000.
31. Zeng D, Xu J, Gu J, et al. Short term traffic flow prediction based on online learning SVR. Washington, DC: IEEE Computer Society/Proceedings of the Workshop on Power Electronics and Intelligent Transportation System, 2008, Pp.616–20.
32. Vapnik V. The Nature of statistical learning theory (2nd ed.) New York, NY: Springer- Verlag, 1999.
33. Cover TM. Geometrical and statistical properties of system of linear inequalities with applications in the pattern recognition. IEEE Transaction on Electronic Computers. 1965; (14):326–34. Available at: http://hebb.mit.edu/courses/9.641/2002/readings/Cover 65.pdf.
34. Sherrod PH. Digital tree regression software for predictive modeling and forecasting (Version 4.0). Brentwood, TN: DTREG Software, 2010. Available at: http://www.dtreg .com.
35. Blaha MJ, Kusz KL, Drake W, et al. Hypertension prevalence awareness, treatment and control in North Nashville. Tenn Med. 2006 Apr; 99(4):35–7.
36. Cho BH, Yu H, Kim KW, et al. Application of irregular and unbalanced data to predict diabetic nephropathy using visualization and feature selection methods. Artif Intell Med. 2008 Jan;42(1):37–53.
37. Wilson SM, Wilson OR, Heaney CD, et al. Use of EPA collaborative problem-solving model to obtain environmental justice in North Carolina. Prog Community Health Partnersh. 2007 Winter;1(4):327–37.
38. Ramesh A, Archibong A, Hood DB , et al. Global environmental distribution and human health effects of polycyclic aromatic hydrocarbons. In: Global trends of persistent organic chemicals. Edited by Loganathan BG and Lam PK, (eds.). Boca Raton, FL: 2012, Pp. 97–126.
39. Al-Hamdan MZ, Crosson WL, Limaye AS, et al. Methods for characterizing fine particulate matter using ground observations and remotely sensed data: potential use for environmental public health surveillance. J Air Waste Manag Assoc. 2009 Jul; 59(7):865–81.
40. Omishakin AA, Carlat JL, Hornsby S, et al. Achieving built-environment and active living goals through Music City moves. Am J Prev Med. 2009 Dec; 37(6 Suppl 2): S412–9.
41. Mosher WD, Jones J, Abma JC. Intended and unintended births in the United States: 1982–2010. Natl Health Stat Report. 2012 Jul 24; (55):1–28.
42. Brown SS, Eisenberg L. The best intentions: unintended pregnancy and the well-being of children and families. Washington, DC: National Academy Press, 1995.
43. Logan C, Holcombe E, Manlove J, et al. The consequences of unintended childbearing: a white paper. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 2007; Available at: http://www.thenationalcampaign.org/resources/pdf/consequences.pdf.
44. Barber JS, Axinn WG, Thornton A. Unwanted childbearing, health, and mother-child relationships. J Health Soc Behav. 1999 Sep;40(3):231–57.
45. David HP. Born unwanted, 35 years later: The Prague Study. Reprod Health Matters. 2006 May;14(27):181–90.
46. Berkson J. Limitations of the application of fourfold table analysis to hospital data.Biometrics. 1946 Jun; 2(3):47–53.
47. Long J, Li Y, Yu Z. A semi-supervised support vector machine approach for parametersetting in motor imagery-based brain computer interfaces. Cogn Neurodyn. 2010 Sep;4(3):207–16.

Continue reading →